The "Domino Flaps" Concept: Functional Composite Reconstruction for Traumatic Transmetacarpal Thumb Amputation

Complex transmetacarpal thumb amputation remains a challenging reconstructive injury. Optimal reconstructive options aim to achieve a neo-thumb with optimal length, sensitivity, stability, and an aesthetically functional result. In cases when immediate replantation of the amputated digit is not possible, a temporary ectopic replantation with staged reconstruction can be deployed. We report our experience of a complex transmetacarpal thumb amputation managed with a staged "domino flap" concept. The first stage involved an ectopic replantation of the amputated digit with a second stage replantation 3 weeks later. Domino flap refers to the requirement of a further reconstruction due to the defect at the donor sites. In this case, the replant is accompanied by 2 domino flap reconstructions with the dorsalis pedis composite free flap to reconstruct the first metatarsal and an anterior tibial artery propeller perforator flap to reconstruct the composite flap donor site.